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SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> FOE QFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-•6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �6 <br /> 'CHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r... ; :. (Complete In Triplicate) _4 <br /> o construct <br /> Application is hereby mad6,. tdesSan Joaquin Local Health Dis istmade inrict rcompliancea permit twith Sa-n Joaquin <br /> and/or install the work herein <br /> ande Rules and Regulations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 ath <br /> I <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION } _ <br /> F1 Phone3 <br /> Owner's Name <br /> city <br /> Address ` V - <br /> f <br /> l Contractor's Name — <br /> TYPE OF WORK (Check): , NEW,L ELL f DEEPEI�T /� RECONDITION_f�T DESTRUCTION J�T <br /> PUMP .INSTALLATION '0 PUMP REPAIR /�J PUMP REPLACEMENT I_T <br /> " other 1 I <br /> SE4FER'LINES i PIT PRIVY <br /> k DISTANCE TO NEAREST: SEPTIC TANK�� D,., CESSPQOL/SEEPAGE PIT / OTHER <br /> I SEWAGE DISP SO AL FIELD PUBLIC DOMESTIC WELL <br /> ' PROPERTY LINE/1PRIiA-TE'•DOMESTIC WELL <br /> INTENDED USE ,TYPE OF WELL i CONSTRUCTION SPECIONS <br /> FICATI <br /> �. — R Cable Tool Dia, of Well Excavation <br /> Industrial. G <br /> Drilled Dia.. of Well Casing <br /> Domestic/private� .i ' Gauge of Casing _ / <br /> Domestic/public i Driven .F <br /> Irrigation Gravel Pack E - Depth of Grout Seal <br /> Rotor Type of Grout <br /> Cathodic Protection . y 1 <br /> Others Other Information " <br /> Disposal Surface Seal _Installed B <br /> Geophysical `�'� ` " <br /> PUMP INSTALLATION" Contractor � g.11 p, <br /> .-Type o �P imp <br /> PUMP REPLACEMENT: State Work Done i i <br /> PUMP .REPAIR: <br /> /_7 S�tateWorkDone 1 <br /> I , <br /> Approximate Depth <br /> DES•TRUC ION OF WELL: Well Diameter <br /> t Desribe. Material .and Procedure <br /> I hereby agree to comply with all Jaws and regulationslof the San Joaquin Local Health District <br /> Within FIFTEEN DAYS <br /> and the State of California pertaining to orregulating <br /> willlfurnishethecSantJoaquin♦Local Health District <br /> t after completion of my work on anew well. <br /> ` WELL DRILLERS REPORT t'e well and notify them before putting the -well in use, The above <br /> information is tx o e --a My knowledge and belief I WILL CALL FOR A GROUT INSPECTION <br /> f PRIOR TO GROUTI .AN A F AL NSP CTI TITLE <br /> k SIGNED „ DRAW PI,-T PLAN ON ,RE Ei2SE SIDE <br /> OR DEP MENT USE ONLY <br /> E PHASE I L DATE <br /> APPLICATION ACCEPT Y' ` ' V�I i,• <br /> ADDITIONAL COMMENTS: Op PHAS I I FI AL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION B DATE <br /> : INSPECTION BY DATE p <br /> �. - 3/76 2M <br /> 1-74 .r, <br />